Even in the Age of Prozac, Some Still Prefer the Couch

By ERICA GOODE

Published: January 28, 2003

Four days a week, Rachel H. takes the subway uptown, waves to the doorman in the large prewar apartment building where her psychoanalyst keeps his office, lies down on a burgundy leather couch and begins to talk.

Ms. H., a 33-year-old graduate student, has heard all the jokes. She has listened patiently to friends who tell her she would be better off taking Prozac or trying yoga or leaving New York altogether to escape her obvious ''dependency'' on her analyst. She has endured teasing and incredulity. ''Don't you think that's so last century?'' asked one woman.

Yet Ms. H. is not bothered by this lack of enthusiasm.

After spending six years and about $60,000 on analysis, she says, she is less self-destructive, more responsible, more productive and more successful in her work. She has more compassion for others. She understands, in ways that have grown more layered and complex, her own strengths and limits and those of the people close to her.

In the last quarter century, psychoanalysis has been declared dead many times over. Psychoanalysts, once dominant in psychiatry, now stand on the sidelines of a field where drug treatments and brief forms of talk therapy are the rule. Thanks in large part to Woody Allen, Freud's talking cure has become shorthand for costly self-indulgence with no obvious benefit. And many psychiatrists barely hide their disdain for what they regard as an outmoded approach to treating mental disorders.

Yet thousands of Americans -- it is not known exactly how many -- continue to seek out psychoanalysis. Like Ms. H., they believe that the arduous, uncertain and often emotionally painful dissection of mental life such treatment entails offers something they can find nowhere else.

''Obviously I think it's an incredibly valuable thing that I'm doing. Otherwise, why would I do it?'' said Ms. H., who spoke on the condition that her last name not be used out of concerns for her privacy.

''You have to see things for what they are, and I think that's essentially all that it's about,'' she said. ''It's about lifting the veil, seeing relationships and seeing yourself, so that you can begin to make choices that will not lock you into an unhappy future and an unhappy life.''

In its heyday in the 1950's and 1960's, psychoanalysis attracted a wide swath of the intellectual elite, along with many middle class patients who, backed by generous health insurance plans, were referred to psychoanalytic treatment as the best psychiatry had to offer.

Experiences on the couch, good or bad, provided routine fodder for dinner parties. And the language of classical psychoanalytic theory -- the unconscious, the Oedipus complex, the superego and the id -- became firmly embedded in the culture.

Yet most psychoanalysts now acknowledge that analysis was practiced far too broadly and that its effectiveness, particularly as a treatment for severe mental illnesses like schizophrenia and manic depression, was greatly oversold.

''Many analysts thought that psychoanalysis was the treatment of choice for virtually every mental disorder,'' said Dr. Kerry J. Sulkowicz, the chairman of the public information committee for the American Psychoanalytic Association, which held its winter meeting in New York last week. ''We've learned that that's not the case.''

Today, pharmacology and focused, short-term psychotherapies predominate in the treatment of mental illness. Psychoanalysts are more cautious about whom they will treat on the couch. And those who seek their help represent a far smaller and more select group.

According to a survey conducted in 2001 by the psychoanalytic association, analytic patients in the United States are typically well educated, well-off financially, white and 30 to 50 years old. Some are mental health professionals, trying to understand themselves better in order to better help their patients. But business people, artists, writers, academics and others also find their way into analysis.

Many have tried other forms of talk therapy and have been dissatisfied with the results. Some have taken, or continue to take, antidepressants or other psychiatric drugs and have found that while helpful, the medications have not solved their problems in forming intimate relationships or in avoiding destructive behavior patterns. Still others remain stubbornly committed to the notion that their emotional difficulties are rooted in the unconscious rather than in the ebb and flow of brain chemicals.

''I had this really strong conviction that my problems were psychological, and I wanted to deal with them psychologically,'' said Patrick Cody, 40, a communications consultant in Washington who spent 10 years in analysis, which he sought out after experiencing depression and severe panic attacks.

In an era of managed care, most patients pay out of their own pockets for their treatment, which typically involves three to five sessions a week, at fees varying from $10 a session at a psychoanalytic training clinic to more than $200 a session at a Park Avenue practice.